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PubMed1994

The triple cold syndrome. Cold hyperalgesia, cold hypoaesthesia and cold skin in peripheral nerve disease.

A syndrome of cold hyperalgesia associated with cold hypoaesthesia is described in 28 patients with peripheral polyneuropathy or mononeuropathy of various aetiologies. A mechanism of sensory disinhibition, where diminished cold-specific A delta input releases cold pain input carried by C nociceptors, is proposed to explain the hyperalgesia. In most patients, the symptomatic skin is abnormally cold. This is a likely consequence of vasospasm, due to sympathetic denervation supersensitivity, caused by dropout of sympathetic efferents as part of the small caliber nerve fibre insult. The term 'triple cold syndrome' is coined to describe this specific pathophysiological condition. Descriptively it is a mirror image of erythralgia, as described by Sir Thomas Lewis (1936) and updated by one of the present authors, a human condition also centred around anomalous primary nociceptor input, in which there is heat hyperalgesia and hot symptomatic skin due to C nociceptor sensitization and vasodilatation from antidromic discharge. Thus, like the latter condition, the triple cold syndrome emerges as an independent clinical entity with definable abnormal mechanisms which should be retrieved out of the all-embracing, descriptive, diagnostic category 'reflex sympathetic dystrophy--causalgia'.

Adult↗
PubMed1994

Visceral afferents: their contribution to 'sympathetic dependent' pain.

For 80 years the sympathetic nervous system has been implicated in certain human pains, notably causalgia and reflex sympathetic dystrophy. This assumption has led to the accepted concept of 'sympathetic dependent' pain. In this critical review, the evidence for this assumption is assessed. It is found that the clinical phenomena suggesting sympathetic nerve involvement may be more satisfactorily attributed to effects of neuropeptides released from afferent C-fibres. The evidence also demonstrates that the effects resembling sympathetic dysfunction relate neither to the pain nor to pain relief following sympathetic blockade. The techniques and results of sympathetic blockade have rarely been adequately evaluated, and the apparent efficacy, specificity and mode of action of peripheral sympatholytic drugs are questioned. An alternative explanation is proposed: that visceral afferents subserve a number of human pains, including those that have been considered sympathetically mediated. Problems of terminology are discussed; use of the term 'visceral afferent' is clarified and broadened to include afferents, particularly those related to blood vessels, which travel within autonomic nerves, in addition to the classical visceral afferent innervation of the organs of the great body cavities. The clinico-anatomical evidence reviewed here indicates that this general and widespread system of afferents could subserve certain pains. The relationship between visceral afferents, somatic afferents and autonomic efferents is outlined, and support is found for the unitary nature of the sensory system envisaged by Langley. Conflicting results from experiments on animals and clinical studies in man on the pain-subserving properties of visceral afferents are summarized; these confirm that visceral afferents can, at least on occasions in man, mediate pain not considered typically 'visceral'. This conclusion receives support from a number of clinical observations: not only are diseases of the autonomic nervous system painless, but damage to previously painless autonomic nerves can generate pain, as illustrated by several different conditions; pain from diseases other than of the viscera of the great cavities and which involves the widespread visceral afferents may be alleviated by sympathetic blockade, presumably since afferents travelling within autonomic fibres are simultaneously blocked; and diseases which impair the function of autonomic nerves may be unexpectedly painless. The central nervous system sequelae following involvement of visceral afferents are outlined and found to be relevant to phenomena sometimes seen with causalgia and related conditions: spread of pain; mirror involvement; associated features such as involuntary movements; and referred pain. Visceral afferents are generally clinically silent unless damage occurs.(ABSTRACT TRUNCATED AT 400 WORDS)

Afferent Pathways↗
PubMed1994

The interpretation of pain relief and sensory changes following sympathetic blockade.

A comparative study of the effects of sympathetic blockade by stellate ganglion block (SGB) and intravenous phentolamine infusion (PhI) was carried out in 24 patients with presumed sympathetically maintained pain of an upper extremity. A total of 15 SGBs and 16 PhIs were performed, with seven patients undergoing both procedures. All patients developed a Horner's syndrome with SGB and nasal stuffiness and cardiovascular changes with PhI. Similar pain relief was obtained with SGB and PhI in six of the seven who underwent both procedures. Pre-procedure patient characteristics including age, sex, duration of pain, historical and physical examination features suggestive of the reflex sympathetic dystrophy syndrome, and sensory disturbances such as allodynia and hyperpathia did not predict pain relief from either procedure. Changes in skin temperature following the sympatholytic procedure did not correlate with pain relief. For PhI, pain relief correlated with the magnitude of decrease in systolic blood pressure. After SGB, changes in quantitative thermal sensory testing (QST) suggestive of a partial deficit in thermal sensation correlated with pain relief. In 20 normal controls, water bath immersion to cool the hand passively by 7 degrees C and warm the hand passively by 4 degrees C had small and selective effects on thermal QST thresholds, but did not produce a general impairment in thermal sensation. In conclusion, the diagnosis of sympathetically maintained pain based on the history and physical examination alone cannot be made with confidence and therefore a sympatholytic procedure is necessary. When SGB produces pain relief but PhI does not, systemic absorption of local anaesthetic and/or sensory blockade by spread to somatic nerves may be the reason. Thus, PhI appears to be a less sensitive but more specific test than SGB. These two procedures provide complementary information and both may be needed to establish the diagnosis of sympathetically maintained pain.

Adult↗
PubMed1983

Stimulation of the peripheral nervous system for pain control.

Transcutaneous stimulation is a proven effective way to relieve pain. Its optimal use requires an accurate patient diagnosis. Treatment of pain as a symptom only is likely to fail. There must be a careful psychosocial evaluation, for the majority of patients who come to the doctor complaining of pain have major psychological, social, or behavioral factors that are most important in the genesis of the complaint. Drug abuse must be corrected. Related symptoms, such as anxiety and depression, must be treated. Then, a thorough trail of transcutaneous stimulation is mandatory. A desultory use will undoubtedly lead to failure. This trial must begin with patient education by experienced personnel. Then the electrodes must be properly applied, and there must be a regular follow-up of stimulation to be certain the patient is utilizing it correctly. The patient must be supported through an adequate trial which should extend over 2-4 weeks before purchase of the device is contemplated. Furthermore, all related nursing and physician personnel must be educated in the proper use of the technique. The uninformed professional who denigrates the therapy is a very effective deterrent to appropriate use. In this situation, transcutaneous electrical stimulation will be of great value in the treatment of acute musculoskeletal injury and acute postoperative pain. It will be effective in the treatment of peripheral nerve injury pain, chronic musculoskeletal abnormalities, chronic pain in the patient who has undergone multiple operations upon the low back and neck, visceral pain, some of the reflex sympathetic dystrophies, and postherpetic neuralgia. Stimulation will not help a complaint which is psychosomatic in origin. It will not influence drug addiction. It is not likely to be useful in any situation where secondary gain is important. The metabolic neuropathies, pain of spinal cord injury, and pain from cerebrovascular accident will not respond frequently enough to warrant more than hopeful trials. The technique is inexpensive, places the patient in control of his own pain, and has no known serious side effects. Its widespread application awaits the development of reasonable systems to provide this service to physicians and patients. Stimulation-induced analgesia deserves a place in the armamentarium of every physician dealing with the complaint of pain.

Back Pain↗
PubMed1991

Mechanisms of sympathetic pain.

In some chronic pain states, notably causalgia and reflex sympathetic dystrophy, activity in sympathetic efferent neurones can exacerbate the pain and sympathectomies relieve it. These patients are said to have sympathetically maintained pain (SMP). In normal tissue, activity in postganglionic sympathetic efferents does not produce pain, nor is it capable of activating nociceptive sensory neurones. It can, however, induce modest firing in some mechanoreceptors. SMP is often held to result from a vicious circle of events which include changes in peripheral and central somatosensory processes, and most importantly a positive feedback element in the form of sympathetic efferent neurones which, by activating sensory neurones in the periphery, completes the vicious circle. Several specific hypotheses have been advanced as to the primary pathophysiological cause of pain in these patients. Suggestions, largely deriving from observations on animal models, include: ephaptic transmission, adrenergic receptors on sensory neurones, indirect coupling of sympathetic and sensory neurones, sensitization of nociceptive afferents, and, in the central nervous system, sensitization of dorsal horn neurones. All these suggestions have some supporting evidence, but none are able to adequately explain all the disturbances seen in patients with SMP.

Chronic Disease↗
PubMed1994

Physician perceptions of the value of physical modalities in the treatment of musculoskeletal disease.

We randomly surveyed 100 specialists in rehabilitation medicine and 100 rheumatologists concerning their perceptions of the value of 11 different physical modalities--cold, active and passive exercise, interferential current, laser, magnetotherapy, microwave, shortwave diathermy, traction, ultrasound and transcutaneous nerve stimulation in the treatment of seven different musculoskeletal conditions--acute arthritis, joint contracture, neck pain, back pain, tendinitis, reflex sympathetic dystrophy and frozen shoulder. There were significant differences in the perceived benefits of modalities which varied by modality and condition. Overall, rehabilitation medicine specialists regarded modalities to be helpful more often than rheumatologists (P < 0.001).

Humans↗
PubMed1995

The risk of infection from epidural analgesia in children: a review of 1620 cases.

We reviewed cases to determine whether suspected or confirmed epidural infection was associated with epidural analgesia for 1620 infants, children, and adolescents treated over a 6-yr period at Children's Hospital, Boston. Postoperative patients (1458/1620) received epidural infusions for a median of 2 days (range, 0-8 days). No postoperative patient had an epidural abscess. One 10-yr-old with terminal malignancy received thoracic epidural analgesia via two successive catheters over a 4-wk period. She had Candida colonization of the epidural space along with necrotic epidural tumor. A second oncology patient and two patients with reflex sympathetic dystrophy were evaluated for epidural abscess, but none was found. We conclude that the risk of epidural infection is quite low in pediatric postoperative patients receiving short-term catheterization. Use of prolonged epidural analgesia in the management of chronic pain in children requires careful monitoring of warning signs of infection.

Abscess↗
PubMed1997

A novel supraclavicular approach to brachial plexus block.

We describe a novel supraclavicular approach to the brachial plexus. Designated as the intersternocleidomastoid technique, this new approach was tested in unembalmed cadavers. It was then applied for evaluation to 150 ASA grade I or II patients scheduled for elective surgery or physiotherapy of the upper limb or for treatment of reflex sympathetic dystrophy associated with painful shoulder. The new approach was easy to master because of a very simple surface landmark, i.e., the triangle formed by the sternocleidomastoid heads, which were visible and palpable in most patients studied (90%). The procedure was effective intraoperatively, providing satisfactory anesthesia in 140 patients (93%), partially satisfactory blocks in 6 (4%), and unsatisfactory blocks in only 4 (3%). The catheter entry point is cephalad enough not to obscure the surgical field on the shoulder. Catheter insertion was successful in 63 of 70 patients. Postoperative analgesia was provided for 48 h or more in 45 patients and for 24 h in 18 patients. Only minor complications were observed: asymptomatic phrenic nerve block in 89 patients (60%), transient Horner's syndrome in 15 (10%), transient recurrent laryngeal nerve blockade in 2, and misplacement of the catheter into the subclavian vein in 1 patient. No pneumothorax was observed.

Adult↗
PubMed2000

Opioid substitution to improve the effectiveness of chronic noncancer pain control: a chart review.

UNLABELLED: We evaluated the efficacy and tolerability of opioids in the long-term management of chronic noncancer pain. This retrospective chart review included 86 outpatients who started receiving, between 1994 and 1998, long-acting opioids. For each patient, the number of different opioids used and the efficacy and tolerability of each opioid prescribed were noted. During a mean follow-up of 8.8 +/- 6.3 mo, the number of opioids used by each patient was 2.3 +/- 1.4. Patient diagnoses were: back pain (31), neuropathy (20), joint pain (13), visceral pain (7), reflex sympathetic dystrophy (7), headache (5), fibromyalgia (3). The first opioid prescribed was effective for 36% of patients, was stopped because of side effects in 30%, and was stopped for ineffectiveness in 34%. Of the remaining patients, the second opioid prescribed after the failure of the first was effective in 31%, the third in 40%, the fourth in 56%, and the fifth in 14%. There was one case of addiction and no case of tolerance. We conclude that if it is necessary to change the opioid prescription because of intolerable side effects or ineffectiveness, the cumulative percentage of efficacy increases with each new opioid tested. Failure of one opioid cannot predict the patient's response to another. IMPLICATIONS: This study showed that if a patient receiving chronic opioid therapy experiences an intolerable side effect or if the drug is ineffective, changing to a different opioid may result in a lessening or elimination of the side effect and/or improved analgesia.

Adult↗
PubMed2001

alpha-1 and alpha-2 Adrenergic antagonists relieve thermal hyperalgesia in experimental mononeuropathy from chronic constriction injury.

Phentolamine, a nonspecific alpha 1- and alpha 2-adrenergic antagonist, relieves pain in patients with reflex sympathetic dystrophy. We sought to determine whether phentolamine, prazosin (alpha 1 antagonist), or SKF86466 (alpha 2 antagonist) relieve thermal hyperalgesia in rats with neuropathic pain. Four days after producing a chronic constriction injury (CCI), thermal hyperalgesia was tested by measuring paw withdrawal latency (PWL). After injection of phentolamine, prazosin, or SKF86466 each at doses of 1, 2, or 5 mg/kg, PWL tests were measured at 5 min and repeated at 15-min intervals for 1 h. Phentolamine, prazosin, and SKF86466 1, 2, and 5 mg/kg provided statistically significant analgesia in rats with CCI for at least 65 min. PWL did not return to baseline levels after 1 or 2 mg/kg of prazosin or SKF86466 but did so after 35 min after phentolamine 2 mg/kg. After 5 mg/kg, PWL returned to preoperative values between 5 and 50 min for phentolamine, at 35 and 65 min for prazosin, and at 50 min for SKF86466. We conclude that both alpha1 and alpha2 peripheral receptors of the sympathetic nervous system are involved in the thermal hyperalgesia caused by CCI and that thermal hyperalgesia can be reversed by both alpha1 and alpha2 antagonists in a dose-dependent manner.

Adrenergic alpha-1 Receptor Antagonists↗
PubMed1995

Arteriovenous differences in plasma concentrations of catechols in rats with neuropathic pain.

BACKGROUND: Alterations in cutaneous temperature, sweating, and cutaneous blood flow in patients with pain states, such as reflex sympathetic dystrophy and causalgia, have been interpreted as evidence for exaggerated sympathetic outflow. It was determined whether pain behavior in a rat model of sympathetically maintained pain is associated with alterations in regional sympathoneural function. METHODS: Peripheral neuropathy was induced in 29 Sprague-Dawley rats by ligation of the left L5 and L6 spinal nerves. Sixteen other rats had sham surgery (nerve exposure without ligation). Animals were tested for behavioral signs of allodynia (decreased paw withdrawal thresholds to mechanical stimuli) at 2 and 4 weeks after the surgery. Arterial and iliac venous blood samples (left, affected; right, control) were obtained at 2 weeks (NP2, n = 14) and 4 weeks (NP4, n = 15) after neuropathic or sham (n = 8 at 2 and 4 weeks) surgery. Plasma concentrations of dihydroxyphenylalanine, dihydroxyphenylacetic acid, dopamine, norepinephrine, and the intraneuronal norepinephrine metabolite, 3,4-dihydroxyphenylglycol, were analyzed in arterial and left and right iliac venous samples. RESULTS: A decrease in paw withdrawal threshold was observed in neuropathic (NP2 and NP4) but not sham-operated rats. Affected and control limbs did not differ in arteriovenous differences in concentrations of dihydroxyphenylalanine, dihydroxyphenylacetic acid, dopamine, or 3,4-dihydroxyphenylglycol. No differences were observed between sham-operated and neuropathic animals in these arteriovenous increments. In contrast, affected limbs of NP2 rats had a reduced arteriovenous increment in norepinephrine concentrations, compared to that in the control side (P < 0.05). CONCLUSIONS: No neurochemical evidence of sympathetic hyperactivity is observed in the rat model of neuropathic pain; if anything, norepinephrine release is decreased in the affected limb. Autonomic disturbances in neuropathic pain are therefore more likely the result of receptor supersensitivity than increased local sympathoneural traffic.

Animals↗
PubMed1996

Single-portal endoscopic carpal tunnel release: agee carpal tunnel release system.

This single-group prospective cohort study was conducted to define the efficacy and safety of single-portal endoscopic carpal tunnel release using the redesigned carpal tunnel release system (3M Healthcare, St Paul, MN). Eighty-six procedures in 69 patients were evaluated by objective motor/sensory testing and clinical outcome questionnaire at 10 days, and 6 and 10 weeks postoperatively. All cases were performed by the same surgeon using a similar local anesthetic technique. The subjective symptoms of carpal tunnel syndrome, including paresthesia, numbness, and pain, demonstrated substantial improvement by 10 days postoperatively, and less than 2% of the subjects remained symptomatic by 10 weeks. The percentage of patients with normal, static, two-point discrimination in the median nerve distribution, demonstrated significant improvement by 6 weeks postoperatively. Preoperative grip and three-point pinch strength were regained by 6 weeks postoperatively, while lateral pinch demonstrated substantial improvement in the same time period. Workers' compensation cases required a significantly longer time to return to work (mean, 40.8 days) than nonworkers' compensation cases (mean, 22.2 days). No difference, however, was demonstrated between workers' compensation and nonworkers' compensation cases with respect to the time of return to activities of daily living (mean, 13.5 days). There were no major neurovascular injuries incurred during the performance of the study. The most important complications included one mild reflex sympathetic dystrophy, three transient digital neuropraxias, and one superficial wound infection. In conclusion, the performance of single-portal endoscopic carpal tunnel release using the redesigned Agee carpal tunnel release system is both a safe and efficacious procedure.

Activities of Daily Living↗
PubMed1998

Two-portal endoscopic carpal tunnel release: an outcome analysis of 333 hands.

Outcome data were collected on 239 patients who underwent endoscopic release of the transverse carpal ligament. The procedure was performed on 333 hands in 239 patients. All patients had failed to respond to nonoperative management for carpal tunnel syndrome and had confirmatory electrodiagnostic studies. Patients underwent follow-up evaluations at 21, 28, and 42 days. Numbness and paresthesias were relieved in 98% of the operated hands, and pain was relieved in 90% of the hands. A satisfactory result was achieved in 325 hands, which resulted in a 98% overall satisfaction rate. Eighty-eight percent of the patients required only two or less doses of oral analgesic during the postoperative period. Only 50 hands undergoing endoscopic release exhibited scar tenderness or pillar pain beyond 28 days. Excluding workers' compensation patients, 83% of the patients returned to work in less than 28 days (average, 14.6 days). No operative complications were encountered, although 1 patient experienced postoperative reflex sympathetic dystrophy, which responded to conservative outpatient treatment.

Adult↗
PubMed2001

Complex regional pain syndrome.

Despite its recommendation by the International Association for the Study of Pain, the term 'complex regional pain syndrome' has not been widely adopted. Most authors still prefer the term 'reflex sympathetic dystrophy'. The diagnostic criteria recommended by the International Association for the Study of Pain have been criticized as lacking specificity, and refined criteria have been proposed. The pathophysiology of the complex regional pain syndrome remains elusive, but most recent work favours a central mechanism both for the sensory features and the autonomic features. Peripheral mechanisms include tissue acidosis. Some investigators, however, view the condition as psycho-neurogenic. Although recommended by some, laboratory tests add little to diagnostic confidence. Certain prophylactic measures have been recommended for patients undergoing surgery, and for the treatment of fractures of the radius. Treatment is still based largely on traditional wisdom. Some new treatments have been promoted on the basis of uncontrolled studies. Controlled studies have indicated possible roles for bisphosphonates and spinal cord stimulation.

Journal Article↗
PubMedDate not supplied

Regional hypothermia in response to minor injury.

Minor injuries are sometimes followed by a potentially disabling syndrome of hyperalgesia, hyperesthesia, allodynia, and sudomotor disturbance as well as, eventually, weakness, muscle atrophy, trophic skin changes, and bone and joint abnormalities. Vasomotor changes frequently present as hypothermia or hyperthermia. Most of the literature refers to this syndrome as reflex sympathetic dystrophy (RSD). To observe possible early RSD changes, we studied 1000 military recruits before and during basic training. Evaluations consisted of lower limb clinical examinations and pain assessment. Infrared images were taken of anterior, posterior, medial, lateral legs, and plantar surface of the feet. If the clinical examination suggested a possible stress fracture, a bone scan was performed. Recruits were studied before training and again each time musculoskeletal complaints arose. The controls were recruits tested before the onset of training who had no musculoskeletal complaints. Two-hundred seven soldiers were injured. Regional hypothermia was noted in 8.6% of all thermograms, with 75% on the left and 25% on the right. The most common injuries causing this phenomenon were ankle pain/sprain and minor foot stress fractures, especially the left metatarsals. Hypothermia occurred within 24 to 48 h, usually beginning in the periphery and ascending proximally, lasting a few days to 6 wk (end of study). None of the recruits developed the full syndrome of RSD during the study period. Whether the continued training, even though modified, helped to prevent this complication or the observed post-traumatic hypothermia has no relationship to RSD needs to be determined.

Adolescent↗
PubMed1991

Rheumatic manifestations of neoplasia.

Neoplasia in an important cause of rheumatic disease. The mechanisms are either direct infiltration of the bone and joint, or indirect infiltration with manifestations distant from the site of neoplastic involvement. Many of the reports reviewed in this article center on direct associations. In particular, there is a report on polymyositis and dermatomyositis and the link with neoplasia. Cases of reflex sympathetic dystrophy are also described in association with neoplasia. There is further discussion on the link of hairy cell leukemia and vasculitis. Other case reports highlight the multiple associations of musculoskeletal disease and neoplasia. These reports include patients with subcutaneous sarcoidosis, ankylosing spondylitis, polychondritis, and systemic sclerosis. Articular manifestations of benign pleural fibromas are described. The existence of these reports, however, does not constitute proof of a causal relationship and the possibility of chance occurrences of two conditions must be considered. Finally, various therapies for cancer are associated with rheumatologic manifestations. Intravesical bacillus Calmette-Guérin has been found to cause an inflammatory polyarthritis. This form of arthritis is similar to experimentally induced adjuvant arthritis in rats that follows immunization with Freund's adjuvant containing Mycobacterium tuberculosis.

BCG Vaccine↗
PubMed1992

Interscalene blocks for chronic upper extremity pain.

A study of 25 patients was carried out to determine the efficacy of interscalene block (ISB) for the treatment of chronic upper extremity pain. An RSD score was used to categorize these patients. Seventeen of the 25 patients had less pain after ISB, and 14 also had increased range of motion of the affected limb. Patients with reflex sympathetic dystrophy (RSD)/causalgia, as well as other chronic pain conditions, improved. ISB was compared with stellate ganglion block (SGB) in patients undergoing both treatments. ISB seemed to be at least as effective as SGB for treatment of RSD/causalgia and may have some advantages over SGB. The role of somatic and sympathetic blockade is discussed.

Adult↗
PubMed1992

High-resolution bone scintigraphy of the adult wrist.

Bony anatomic landmarks of the wrist (e.g., pisiform, hook of hamate, radioulnar joint, and styloid processes of the radius and ulna) were routinely identified in 28 adult patients examined for wrist pain. With the wrists prone and immobilized, bone scintigrams were obtained for 500,000 counts with an asymmetric (133 to 161 keV) Tc-99m energy window and either a converging (best choice) or straight-bore, high-resolution collimator. High-resolution scintigraphy precisely localized degenerative joint disease (nine patients), scaphoid fractures (five), pisiform fracture (one), lunate avascular necrosis (one), radioulnar arthritis (one), septic or inflammatory arthritis (six), ulnocarpal impingement (two), and reflex sympathetic dystrophy syndrome (two). Images obtained palm down with the wrist in ulnar deviation helped identify increased uptake within the scaphoid. Fracture and significant bone or joint disease were excluded in one patient.

Adult↗